Solution-Focused Brief Therapy With People With Mild Intellectual Disabilities: A Case Series

Solution-Focused Brief Therapy With People WithMild Intellectual Disabilities: A Case Seriesjppi_317 247..255

John M. Roeden*,‡, Marian A. Maaskant†,‡,§, Fredrike P. Bannink¶, and Leopold M. G. Curfs‡,***Baalderborg Groep, Hardenberg; †Department of Health Care and Nursing Science; ‡Governor Kremers Centre, MaastrichtUniversity; §Pergamijn, Echt; ¶Therapy, Training, Coaching and Mediation Practice, Amsterdam; and **Department of ClinicalGenetics, Academic Hospital Maastricht, the Netherlands

Abstract Solution-focused brief therapy (SFBT) is a form of behavior therapy that focuses on evoking desired behavior rather thanon the existing problem behavior. To illustrate the use of this form of therapy, the authors undertook a study of 10 case studies ofapplications of SFBT with people with a mild intellectual disability (MID). For all 10 cases, before SFBT, after SFBT, and during afollow-up after 6 weeks, the following measurements were taken: assessment of quality of life and assessment of maladaptive behavioras well as goal attainment according to people with MID and according to carers. It was found that SFBT treatments contributed toimprovements in psychological functioning and decreases in maladaptive behavior. In addition, achievement of goal attainments werenoted according to both people with MID and their carers. The positive changes evident after SFBT proved sustainable duringfollow-up. Treatment strategies and therapeutic alliances employed were usually assessed as positive by the participants. Although thestudy had limitations due to the lack of a control group and the small number of cases, the fact that several case studies showedpositive treatments results did indicate the effectiveness of SFBT for people with MID.

Keywords: behavior therapy, challenging behavior, intellectual disabilities, solution-focused brief therapy

INTRODUCTION

Psychological problems frequently occur in people with intel-lectual disability (ID). Compared with other people, adults withID are reported to experience many more behavior problems orpsychiatric disorders (Cooper, Smiley, Morrison, Williamson, &Allan, 2007; Crews, Bonaventura, & Rowe, 1994; Didden, Collin,& Curfs, 2009; Menolascino, Levitas, & Greiner, 1986). Varioustherapies have been developed to positively influence behaviorsuch as environmental adaptations, behavior therapies, andfamily therapy (Beail, 2001; Beail, Kellett, Newman, & Warden,2007; Beail, Warden, Morsley, & Newman, 2005; Newman &Beail, 2002). Solution-focused brief therapy (SFBT; De Shazer,1985) is a behaviorally orientated treatment that has gainedpopularity over the past 25 years. SFBT represents a short-term,goal-focused, and client-directed therapeutic approach that helpsthe client focus on solutions rather than problems.

The aim of this study was to illustrate the efficacy of applica-tions, processes, and effectiveness of SFBT in people with mildID (MID). To proceed, we first explain the assumptions andprocesses of SFBT and its use for people with ID. Thereafter, weconsider the processes and applications of SFBT with people withMID and then describe the results and conclusions.

SFBT: Assumptions and Processes

One of the central assumptions of SFBT is that the goal of thetherapy is defined by the client and that the client has the com-petencies and resources to realize this goal. During this process,the client is invited to describe what will be different in the futureonce his or her goal has been reached and to explore exceptions tothe problems (times when problem behavior does not occur). Thetherapist stimulates the client to describe progression toward thetherapy goal in specific, small, behavioral steps. The therapist alsosuggests tasks such as “continue with what is working already” inorder to stimulate or maintain changes. At the start, variationsin the relationship with the client (i.e., whether it is visitor, com-plainant, or customer relationship) are assessed and identified.In a visitor relationship, the client is referred to the therapist byothers. In this relationship, the client does not voluntarily seekhelp and is not experiencing emotional difficulties. In a complain-ant relationship, the client does have a problem and experiencesemotional difficulties, but he or she does not (yet) see himself orherself as part of the problem and/or the solution. In a customerrelationship, the client does see himself or herself as part of theproblem and/or solution and is motivated to change his or herbehavior. Each type of relationship requires different approachesby the solution-focused therapist toward the client. For example,in the visitor relationship, the therapist may ask what the referrerwould like to be different in the future and to what extent theclient is prepared (at a minimum or maximum) to cooperatein the process. In the complainant relationship, the therapist

Received December 29, 2010; accepted July 27, 2011Correspondence: John Roeden, Baalderborg Groep, Vlasakkerkamp 19,Hardenberg 7772 MK, the Netherlands. Tel: +31 523 287128; E-mail:[email protected]

Journal of Policy and Practice in Intellectual DisabilitiesVolume 8 Number 4 pp 247–255 December 2011

© 2011 International Association for the Scientific Study of Intellectual Disabilities and Wiley Periodicals, Inc.

acknowledges the client’s difficulties and gives suggestions forobserving the moments when the problem is or was there to alesser extent. In the customer relationship, the client may be givena behavior assignment (e.g., “continue with what is workingalready”).

SFBT: Use With People With ID

SFBT has a number of advantages that makes it attractive foruse with people with ID. These include: focus on empowermentand on skills rather than on deficits, unique interventions for eachperson based on particular skills and needs, and recognition ofthe expert status of the individual resulting in a sense of self-efficacy within the therapeutic relationship (Roeden, Maaskant, &Curfs, 2011). SFBT regards the client as expert, and thus is in linewith the present view on ID that focuses on empowerment andcompetencies of people with ID (Gallant, Beaulieu, & Carnevalle,2002; Martin, 2006). Several authors have suggested adjustmentsto SFBT as it was originally described by De Shazer (1985) forpeople with ID, due to their specific needs, developmental,emotional, and cognitive levels and abilities (Corcoran, 2002;Lentham, 2002; Murphy & Davis, 2005; Roeden & Bannink,2007a, 2007b; Roeden, Bannink, Maaskant, & Curfs, 2009; Smith,2005, 2006; Stoddart, McDonnel, Temple, & Mustata, 2001; Teall,2000; Westra & Bannink, 2006a, 2006b).

These recommendations include the use of simple language,flexibility in questioning, and allowing the person with IDenough time to answer questions, develop ideas, and reflect onwhat is transpiring during sessions. Also, it is advantageous to usevisual aids, such as emoticons and drawings, to involve carers andfamily, to encourage and explain tasks, and to adapt task assign-ments (such as the use of prompts and written or visual aids). Inapplication to the general population, SFBT has been the subjectof an increasing number of outcome studies (cf. Bannink, 2010;MacDonald, 2007). Stams, Dekovic, Buist, and de Vries (2006)conducted a meta-analysis of SFBT in which they compared 21studies and noted a modest positive effect of SFBT in a short time(an average of six SFBT sessions). However, research literature onthe use of SFBT among people with ID is scarce, but that whichis available has been shown to have some promising positivetreatment effects. Stoddart et al. (2001), for example, reviewed 16people with mild to borderline ID receiving SFBT. Cliniciansrated the degree to which the outcomes, as ascertained fromclient records, were successful on a five-point Likert-style scale(1 = unsuccessful to 5 = very successful). Using this method,problems relating to poor self-esteem, family relationships, andbereavement were most successfully treated with SFBT (successratings 3.7–5.0), whereas depression and anxiety, couple conflict,and independence issues showed the least improvement (successrating 2.0–3.3).

Because more information was needed as to the usefulnessof applications of SFBT with adults with MID, we conducted anexploratory study of SFBT procedures with 10 people who hadexperienced adjustment difficulties. We expected that SFBT couldassist them in improving their quality of life, in reducing mal-adaptive behaviors, and in attaining their treatment goals. Inaddition, we expected that participants in this study would appre-ciate the SFBT experience. As part of our study, we first described

the treatment protocol. Second, we collected data by measuringdifferences before SFBT, directly after SFBT, and 6 weeks afterSFBT, with regard to three variables or outcomes. These werequality of life, maladaptive behavior, and goal-attainment percep-tions according to both adults with MID and their staff carers.Third, to get at the experiential variables, we collected opinionsabout the SFBT procedure and the collaborations from our 10subjects.

METHODOLOGY

The study was conducted at the program sites of a serviceprovider for children and adults with ID (serving approximately900 people) in the Netherlands. People enrolled with this pro-vider use various residential services such as day care and homecare. This service provider employs, among others, qualified psy-chological therapists, and one of the services offered is SFBT.

Participants and Procedure

Participants Ten of the provider’s clients were nominated toparticipate in the study as they all had some “issue” that war-ranted change, and it was thought that SFBT would be the meansto make those changes. The 10 participants (labeled C1–C10 in thetables) lived semi-independently and received individual support(ranging from 2 to 14 h per week) from staff carers employed bythe service provider mentioned previously. The support theyreceived included help with housekeeping tasks (such as cleaningand cooking), with financial tasks (such as banking), and withsocial-emotional tasks (such as dealing with other people andconflict management). All participants (three men and sevenwomen with a mean age of 39 years) in the study had MIDdetermined on the basis of intelligence quotient (tested bymeans of the WISC-III-NL (Wechsler, 2005a) or the WAIS-III-NL(Wechsler, 2005b)) and adaptive functioning (tested by means ofthe SRZ-plus—a Dutch adaptive behavior scale—Kraijer &Kema, 1994). None of the participants had acute psychiatric con-ditions. All participants had been referred for SFBT by their staffcarers.

All of the participants agreed to participate in the study andprovided permission for anonymous publication of the studydata. Permission for the research study was given by the clientcouncil (made up of clients with ID) and by the organization’sclient representative council (family members or other represen-tatives of people with ID). Both councils acknowledged that theresearch proposal corresponded to guidelines for carrying outresearch projects involving people with ID in the Netherlands.

Procedure The study was composed of 10 SFBT applicationswith five sessions each. The sessions and treatment protocol aredescribed in Table 1. The average duration of the five SFBT ses-sions was 12 weeks. Every SFBT session was attended by at leastthree people: the person with MID, the staff carer, and the thera-pist. In our application of SFBT, we decided that every personwith MID would be accompanied by a carer. This was because itappeared from the treatment practice of SFBT that the interven-tions are better understood and executed when carers perform a

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supportive role in the treatment procedure (Roeden & Bannink,2007a; Stoddart et al., 2001; Teall, 2000). The following problemswere reported by the 10 participants and their staff carers: alcoholabuse (three adults), anger (two adults), bereavement (one adult),depression/apathy (one adult), sleeplessness (one adult), low self-esteem (one adult), and avoidance/anxiety (one adult). In eachapplication, three data measurements were taken: the first imme-diately before SFBT, the second immediately after ending SFBT,and the third during a follow-up measurement 6 weeks afterSFBT. The measures provided objective information about thetreatment effects derived from standardized measuring instru-ments and assessment information on the clients’ and carers’

opinions about treatment effects and treatment processes. Tobe able to determine whether differences existed at individuallevel between the before, after, and follow-up measurements,the criteria for statistically significant and/or clinically relevantdifferences for each measure were determined a priori.

Statistical analysis Because of the relatively small sample size(10 clients), a nonparametric test (Wilcoxon signed-rank test)was used to analyze the data, rather than a parametric test. TheWilcoxon signed-rank test, a nonparametric statistical hypothesistest for repeated measurements, was performed on four variables:quality of life, psychological functioning, social functioning

TABLE 1SFBT treatment protocol with sessions, interventions, and descriptions

Session Intervention Description

Intake Getting acquainted The therapist spends time to get to know the client. Competencies andresources are being explored.

Exploring the problem The therapist invites the client to describe his or her problem and/or tomention his or her goal for the treatment.

First session Pre-session change As most clients have tried other possibilities before connecting with atherapist, the therapist can ask whether what changes have already occurredbefore the first session.

Goal setting The client is invited to describe what would be different once his or her goalis reached. This could be done by means of the “miracle question”(“Imagine a miracle occurring tonight that would [sufficiently] solve theproblem . . . what would be different tomorrow?”). The therapist may alsosuggest that changes are possible (e.g., “when you look forward and thingshave improved, what will you be doing differently?”).

Exploring the exceptions The therapist inquires about moments in the past or present when theproblem did not or does not occur or is less serious and who does what tobring about these exceptions.

Scaling questions On a scale of 10 to 1, the client indicates his or her progression toward thegoal. Scaling questions help the client to move away from all-or-nothinggoals toward manageable and measurable steps.

Competence questions By using competence questions, self-compliments are being provoked withthe client. “How do (did) you do that?” Direct compliments are aimed atsomething the client has done, made, or said.

The question: “what else?” The therapist may also indicate with the question “what else?” that there ismore to come. Clients often respond to this simple query by giving moreinformation and ideas.

Feedback At the end of every session, feedback with compliments and usually somehomework are given. The compliments emphasize what the client is alreadydoing to reach his or her goal. The suggestions indicate areas requiring theclient’s attention or possible further actions to reach his or her goal.Between the components compliments and suggestions/tasks a reason(or bridge) is given to perform those tasks.

Follow-upsessions

The question: “What is better?” The standard beginning question is: “What is better?”EARS = Eliciting, Amplifying,

Reinforcing, and Start againEliciting, amplifying, and reinforcing of (small) successes, exceptions to

problems, or descriptions of the desired future and the invitation to theclient to do that again or more often.

Feedback Compliments—bridge—tasks

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(using the the Intellectual Disability Quality of Life (IDQOL-16),see Measures section), and goal attainment (using the ScalingQuestion Progression (SQP), see Measures section). In order tocontrol the problem of multiple comparisons, the Dunn–Bonferroni correction (Dunn, 1961) was used by dividing thep-value by the number of variables: a/n = 0.05/4 = 0.0125 (round0.01).

Treatment protocol The treatment protocol consisted of sevenmeetings: an intake, five solution-focused sessions, and a follow-up. Every treatment followed the protocol as summarized inTable 1. During the intake, the strengths as well as the problems ofthe person with MID were assessed. At intake, the therapist askedabout work, study, hobbies, interests, skills, talents, and significantpeople in the life of the adult. This information was used in thetreatment sessions. The therapist did not ask questions about thedetails of the problem (because SFBT does not primarily focuson analyzing problems). In the first session, the therapist askedsolution-focused questions, as well as queries about the goals ofthe person with MID, questions about exceptions to problembehavior, and questions about scaling and competence. Every first(and subsequent) session was ended by giving feedback to theperson with MID and to the staff carer.

In the second and subsequent sessions, the therapist startedwith the “EARS-question” set. EARS is an acronym for Eliciting,Amplifying, Reinforcing, and Start again and outlines the thera-peutic process. The first question was: “What is better?” The indi-vidual could respond to that question in four different ways: “It isbetter,”“There is no change,”“It is worse,” or “There is a differencein opinion” (in this case between the opinions of the person withMID and the staff carer). If the situation was better, the therapistcould react to that by amplifying, “What exactly is (somewhat)better?” by reinforcing, “How did you manage to do that?” and bystarting again, “What (else) is better?”—EARS could also be usedif the person thought there was no change. The therapist thenacknowledged the client’s possible disappointment and stressedthe point that keeping things stable was also a good accomplish-ment. Then, the therapist requested the individual to explain howhe or she did that. If the situation was worsening and the personwith MID was disappointed, the therapist also acknowledged this.A reorientation to the goal might be necessary or the therapistcould ask the person how he or she managed to keep goingunder difficult circumstances. That offered a possible reentry tothe EARS set of questions. If there were differences in opinionsbetween the person with MID and the carer about the amount ofprogress, the therapist firstly normalized this situation by suggest-ing that progress usually happens in steps and by trial and error.Subsequently, small improvements could be explored throughEARS. An illustration of a solution-focused consultation is pre-sented in an elaboration of a case description in Table 2.

Measures

Quality of life IDQOL-16 (Hoekman, Douma, Kersten, Schuur-man, & Koopman, 2001) was used to measure the quality of life ofthe person being examined. The IDQOL-16 has three subscales:psychological functioning, social functioning, and satisfaction abouthousing. The IDQOL-16 has proved to have a good internal

consistency (Cronbrach’s a of the various subscales between 0.73and 0.80). Every question had five response categories rangingfrom very pleasant to very unpleasant, made clear by a pictogram(smiley). Raw scores of the subscales were transformed into quar-tile scores (rating of 1–4; higher quartiles are indicative of highersatisfaction). For the total scores (1–10), high deciles were indica-tive of higher satisfaction. In this study, an improvement wasdefined as an increase of one quartile (= 25% improvement) inthe subscales of psychological and social functioning, and anincrease of 2 deciles (= 20% improvement) of the total score(= quality of life). The subscale of satisfaction about housing wasnot included in the treatment results because housing satisfactionis not a primary goal of SFBT.

Maladaptive behavior The Reiss Screen for Maladaptive Behav-ior (RSMB; Reiss, van Minnen, & Hoogduin, 1994) was used tomeasure maladaptive behavior. The RSMB measures the presenceof psychological problems. The RSMB was completed by a staffcarer who had knowledge of the person being evaluated. The listof questions comprised nine subdivisions: aggression, autism,psychosis, depression (behavior symptoms), depression (vitalsymptoms), paranoia, dependent personality disorder, avoidantdisorder, and “other maladaptive behavior.” The internal consis-tency of the nine subdivisions ranged from reasonable to good(Cronbach’s a: between 0.69 and 0.87). The stability was onlycalculated for the total score and was good (Pearson’s r: 0.81). Theinter-rater reliability for the subdivisions ranged from reasonableto good (Pearson’s r: between 0.50 and 0.84). For each item, thestaff carer evaluated behavior items as to whether it was “noproblem” (0 points), to be “a problem” (1 point), or to be a “bigproblem” (2 points) for each person. For each subdivision, theRSMB gave cutoff scores, indicative of the presence of psychopa-thology in people with MID. In this study, improvement of mal-adaptive behavior was defined as a change in one or more scores ina subdivision from above the cutoff score to below the cutoff score.

Goal attainment according to people with MID SQP uses a scale of10 (goal reached) to 1 (goal not reached) on which the individualindicates to what extent he or she has approached or has reachedthe therapeutic treatment goal (Bannink, 2010). In a study byFischer (2009), the scale question was used with 3,920 clients tomeasure emotional coping and daily functioning before and afterSFBT. Differences between before and after SFBT varied between+0.9 and +2.1 points for daily functioning and between +0.6 and+1.4 point for emotional coping. In this study, a progression of +2points (being relatively high) was regarded as clinically relevant.

Goal attainment according to carers Goal Attainment Scaling(GAS; Kiresuk & Sherman, 1968; Kiresuk, Smith, & Cardillo,1994; Schlosser, 2004) is a technique used to evaluate an indivi-dual’s progression toward a goal. For each goal, a five-point scaleranging from -2 to +2 was established. No differences in goalattainment were scored as 0. A positive change toward the goalwas scored as +1 and a negative change was scored at -1. Reachingthe goal was scored as +2 and a severe regression from the startsituation by -2. In addition, an indicator was chosen. The indi-cators were measures of the effect of the intervention in thedirection of the goal (e.g., “number of glasses beer per day”).To obtain a GAS, all scores were added and transformed into a



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standardized GAS index,1 described by Kiresuk and Sherman(1968). Improvement, in the present study, was defined as anincrease of 10 points (or more) on this GAS index. The GAS wascompleted by carers during the therapy sessions.

Treatment strategy and therapeutic alliance Miller, Hubble, andDuncan (1996) developed the Session Rating Scale (SRS). Aversion of the SRS for children was adapted for use with people

1GAS score: I = index = 10 S W i Xi/√[(1–P) SWi2 + P (SWi)2], in whichXi = the score of the ith scale, Wi = the weight assigned to the ith scale, andP = the weighted mean intercorrelation between scales, estimated to be 0.30. Ifall goals are considered to be of equal weight, then Wi = 1 and the indices can

be read from a table compiled by Kiresuk, Smith, and Cardillo (1994). Thecalculation procedure is such that with a large number of indices the averagewill be 50 with a standard deviation of 10. Increases on subscales of +2 (twogoals) or +3 (three goals) are in accordance with an increase of the GAS indexlarger than the standard deviation (>10).

TABLE 2An example case description of the use of SFBT

SFBT treatmentprotocol Session particularsIntervention Description

Gettingacquainted

Mr. E. (a 44-year-old man) mentioned that his interests were listening to music and making music (karaoke),gardening, and doing odd jobs. Mr. E. liked to visit people. The carer added that Mr. E. did not mind change, thatMr. E. was precise, helpful, and social, and that Mr. E. had overcome difficult problems in the past. InSFBT terminology, the therapist and Mr. E. had a client-typical relationship.

Exploring theproblem

The problem with Mr. E. was lack of confidence, which was revealed by frequently asking for confirmation,pondering about his own functioning, and a tendency toward perfectionism.Even though incidental excessive alcohol use resulted in temporary relaxation, it also caused a distressing long-termfeeling of guilt afterward.

Pre-sessionchange

Mr. E. had already informed a number of bar owners and a family member that he wanted to drink alcoholresponsibly.

Goal setting The therapist asked: “Suppose we make a video that shows you are doing well. . . what kinds of things would wesee and hear on that video?” Mr. E. said: “Then I would have self-confidence,” and “Then my head is not so full of‘red’ [worrisome] thoughts.” In exchange for the problem, Mr. E. wanted to have “ ‘green’ [light] thoughts” anddrink alcohol-free beer more often instead of beer with alcohol. Green and red were the words that Mr. E. came upwith himself to describe his thoughts.

Exploring theexceptions

Mr. E. said, “When I am occupied then I feel better.” Mr. E. suggested that carers could assist him in planning adifficult day off. This meant that a well-filled day program during days off or on weekends would keep him fromdrinking too much alcohol.

Scalingquestion

The therapist asked, “Suppose 10 means you have self-confidence and 1 means you don’t have self-confidence, whatmark do you give yourself at this moment?” Mr. E. indicated he was at a 4. After asking what that 4 included andwhat could be done to reach a 5, Mr. E. and his carer came up with many ideas while answering these scalingquestions: They could practice with chit chat (green thoughts), difficult days could be prepared together, Mr. E.could spend his free time volunteering at the local petting zoo, Mr. E. could tell bar owners that he wanted to drinkless alcohol and preferred to drink alcohol-free beer instead, and Mr. E. could practice in steps orderingalcohol-free beer at a bar. Moreover, they could install a token system for alcoholic beer drinking on the weekend(one token = one beer, a maximum of three beers per evening). Planning this way, successes could be rewardedwith short outings (go somewhere to have coffee). In case of continued success, Mr. E. wanted to reward himselfwith the purchase of karaoke equipment.

Feedback Mr. E. viewed himself as part of the problem and the solution (a client-typical relationship). The therapist gave Mr.E. compliments about his resourcefulness (many ideas for improvement) and formulated a reason/bridge (“youhave already started to deal with your problem”). The therapist suggested a task, building on the ideas from Mr. E.and his carer. The behavioral task was: “continue with the things that work already” (e.g., creating and using atoken system).

Follow-upsession(s)

Mr. E. and his carer produced a detailed report about Mr. E.’s increasing control over his alcohol use, and Mr. E.’ssuccess in finding leisure activities. The report also noted Mr. E.’s increase in green thoughts and the intentionto celebrate the successes with a karaoke party.

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with ID by Westra (2008). In this adaptation, words that could beregarded as childish by adults with ID were replaced. The adapteditems were: (1) “the person did not”—vs.—“did listen to me,” (2)“the subjects we talked about were not”—vs.—“were importantto me,” (3) “the way we worked was not good”—vs.—“was good forme,” and (4) “something was missing in the treatmenttoday”—vs.—“I enjoyed the treatment today.” At the end of eachmeeting, the person with MID provided the therapist with feed-back on four areas: (1) the relationship, (2) goals and subjects,(3) strategy or method, and (4) the session. The person was askedto evaluate the consultation using a 10-cm-long line (the scale),representing each one of the four SRS dimensions. The left-handend of the scale was represented by a sad face “smiley” ( ), and theright-hand end of the scale was represented by a happy face“smiley” ( ). The smileys were used to enable the adult to expresssatisfaction. The closest centimeter mark, indicated with a cross,to the right or the left determined the score. The SRS (version foradults) was investigated by Duncan, Miller, and Sparks (2004)and had good internal consistency (Cronbrach’s a: 0.88) andreasonable stability (Pearson’s r: 0.64). A statistically significantcorrelation (Pearson’s r: 0.48; p < 0.01) was found between theSRS and an extensive list of questions with the same measuringpretension (therapeutic alliance). The authors of the SRS recom-mend asking the client to comment on an aspect ofthe treatment strategy or the therapeutic alliance, whenever asubscale score is below 9.

RESULTS

Quality of Life, Maladaptive Behavior, and Goal Attainment

This study focused on the differences before SFBT, directlyafter SFBT, and 6 weeks after SFBT, with regard to (1) quality oflife, (2) maladaptive behavior, (3) goal attainment according topeople with MID, and (4) goal attainment according to carers.

Quality of life In seven of the 10 adults, statistically significantimprovements were evident directly after SFBT using the IDQOLsubscale of psychological functioning. In two of 10 adults, thesame was true for social functioning, and in four of 10 adults, thiswas true for quality of life composite score. During follow-up, thedifferences in psychological functioning and quality of life weresustained in six and four adults, respectively. For social function-ing, two adults prolonged or improved positive changes, and twoother adults showed improvements only at follow-up. These sub-sequent improvements of social functioning in the period afterSFBT, and before follow-up, might be because some of the steps(toward the goals) required more time than the limited timeallotment for the therapy. An example of this is one woman whoorganized a successful reunion with her sister 3 weeks after SFBTand 3 weeks before follow-up, resulting in a higher social func-tioning score.

The differences in scores of all 10 adults were statisticallysignificant (Wilcoxon signed-rank test) for the measures ofquality of life and psychological functioning (quality of life:session 1 vs. session 5; z = –2.7, p < 0.01; session 1 vs. follow-up:z = –2.5, p < 0.01; psychological functioning: session 1 vs. session

5; z = –2.7, p < 0.01; session 1 vs. follow-up: z = –2.4, p < 0.01).No statistically significant changes were seen between social func-tioning scores.

Maladaptive behavior In eight of the 10 adults, staff carersassessed that there were clinically relevant decreases of psycho-logical problems directly after SFBT and during follow-up bymeans of RSMB scores. For two of the 10 people, this concerneddecreases in psychological problems in one domain from the firstto the fifth session, respectively, and the follow-up session (from1 to 0 to 0 scores). For six of the 10 adults, there were decreasesin several domains (from 6 to 3 to 1 domain; from 2 to 0 to 0domains; from 7 to 4 to 5 domains; from 5 to 3 to 3 domains;from 7 to 5 to 3 domains and from 7 to 3 to 2 domains). In twoadults, carers assessed no decreases in psychological problemsfrom the first to the fifth session, respectively, and the follow-upsession (from 1 to 1 to 1 domain). Table 3 lists the outcomes ofthe IDQOL-16 and the RSMB before SFBT, after SFBT, and 6weeks after SFBT (follow-up).

Goal attainment according to people with MID Seven of 10adults indicated progressions of two points or more (a clinicallyrelevant difference) on SQP after SFBT, and these progressionswere sustained during follow-up. The differences in scores of the10 adults were statistically significant (SQP: session 1 vs. session 5;z = –2.8, p < 0.01; SQP: session 1 vs. follow-up: z = –2.7, p < 0.01).

Goal attainment according to staff carers In seven of the 10adults, statistically significant improvements of the GAS index(>10 points) directly after SFBT and during follow-up wereevident. Table 4 shows the outcomes of the SQP and of the GAS.

Opinions about the strategy and collaboration The third topicconcerned the client’s opinions about the strategies and of thecollaboration between the therapist and people with MID, asmeasured by the SRS. All adults gave the minimal desired score of9 to almost all of the item scores. Two incidental lower scores andthe following feedback led to adjustments during therapy (e.g.,“use simpler language and clarify the tasks” (score 7 on relation-ship and approach in session 2) and “give more attention to meand less to the caregiver” (score 8 on relationship in session 2)).

DISCUSSION

In most of the SFBT treatments described in this article, weobserved improvements of psychological functioning, decreasesin maladaptive behavior, and positive progressions toward thetreatment goals according to both adults with MID and staffcarers. Seven of 10 adults with MID reached their treatment goalmeasured by the SQP. For the others, the progression was 0–1point. Two people (cases C2 and C3) at the first session were sodriven to reach their goal (i.e., being in control of alcohol con-sumption during the weekend) that they instantly indicated highprogression scores of 9 and 10. In these cases, clinically significantprogression (SQP � 2 points) was not possible. However, in bothcases, progression toward the treatment goal was confirmed bycarers by means of statistically significant improvements on thegoal-attainment index (GAS > 10). The treatment strategies and



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TABLE 3Intellectual Disability Quality of Life (IDQOL): standard scores per case and Reiss Screen Maladaptive Behavior (RSMB): number ofdomains per case

SFBT session Cases C1 C2 C3 C4 C5 C6 C7 C8 C9 C10

IDQOL subscale: psychological functioningFirst session Raw score 1 3 1 1 1 1 1 1 1 2Fifth session Raw score 2a 3 3a 2a 2a 2a 1 1 2a 3a

Follow-up Raw score 1 3 3b 2b 3b 3b 1 1 2b 3b

IDQOL subscale: social functioningFirst session Raw score 1 1 3 1 1 1 1 1 1 1Fifth session Raw score 2a 1 3 1 2a 1 1 1 1 1Follow-up Raw score 2b 1 3 1 3b 2b 2b 1 1 1

IDQOL subscale: quality of lifeFirst session Raw score 2 3 4 2 2 1 1 1 1 2Fifth session Raw score 5a 3 5 3 6a 4a 1 2 3a 3Follow-up Raw score 4b 3 5 3 6b 6b 2 2 4b 3

Reiss screen for maladaptive behaviorFirst session Domains 6 1 1 2 7 1 5 7 7 1Fifth session Domains 3c 0c 0c 0c 4c 1 3c 5c 3c 1Follow-up Domains 1d 0d 0d 0d 5d 1 3d 3d 2d 1

aPositive difference: the differences were statistically significant: increase of �1 point (= 1 quartile or 25% improvement) in the subscales psychological and socialfunctioning and an increase of �2 points (= 2 deciles or 20% improvement) in the subscale quality of life.bSustained positive statistically significant difference at follow-up.cThe decrease of the number of domains was clinically significant.dSustained decrease at follow-up.SFBT, solution-focused brief therapy.

TABLE 4Goal attainment according to clients (SQP) and according to caregivers (GAS)

Case Nr. C1 C2 C3 C4 C5 C6 C7 C8 C9 C10

Goal attainment according to clients (SQP)After SFBT Scale score +3a +1 +1 +5a +3a +3a +1 +2a +3a +2a

Follow-up Scale score +3b +1 +1 +5b +2b +4b +1 +3b +3b +2b

Goal attainment according to caregivers (GAS)Number of goals 3 2 2 3 3 2 2 2 2 2After SFBT Scale scoree +2 +2c +3c +3c +3c +2c +1 +1 +2c +2c

GAS indexf 59 62c 69c 64c 64c 62c 56 56 62c 62c

Follow-up Scale scoree +2 +2d +3d +3d +4d +3d +1 +1 +3d +2d

GAS indexf 59 62d 69d 64d 68d 69d 56 56 69d 62d

aPositive difference: the differences were clinically significant (� +2 points on the SQP).bSustained positive difference at follow-up.cPositive difference: the differences were statistically significant (� +2 for two goals; � +3 for three goals; >10 for the GAS index).dSustained positive difference at follow-up.eThe scale of the GAS at the start of therapy is zero.fThe GAS index at the start of therapy is 50.SFBT, solution-focused brief therapy; SQP, Scaling Question Progression; GAS, Goal Attainment Scaling.



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therapeutic alliances were generally assessed as positive by thepeople with MID (score of 9 and higher). Discussions about thelower scores led in all cases to workable adjustments (e.g., byclarifying tasks after SFBT using pictograms). These results seemto indicate that SFBT could constitute a valuable contribution tothe support of people with MID.

Our research study has had some limitations. The first is howwe chose our participants. They were selected by staff at theprovider and not randomly. This may affect our results as theremay have been an inclination by the chosen adults to be helpfuland more compliant. Second is the instrumentation. Any choiceof standardized measurement instruments automatically impliesrestrictions. During SFBT, as every person formulated his or herown goal, it is possible that the chosen goal did not sufficientlymatch the measuring pretension of the instruments used. Thisdoes not apply to the SQP because this measurement adjusts itselfto the goal of the individual and is therefore not considereda standardized measurement instrument. It was true for theIDQOL because the domains of psychological and social func-tioning within this instrument were broad and could differ fromwhat people with MID found relevant to measure. Moreover, it isdifficult to conclude from this study whether the improvementsadvanced by participating in SFBT can be seen holding over time.Even though SFBT is considered a brief therapy, it was expectedthat SFBT could assist people with MID in reaching their goals,could improve their psychological and social functioning, andcould reduce psychological problems in a relatively short time.Although some gains were made by the interventions, it remainsuncertain if these improvements will last over time (e.g., longerthan 1 year). A third limitation was our design. We used a designthat did not draw up a control group. We only studied a treatmentgroup and compared measurements taken before SFBT, afterSFBT, and at follow-up. Without comparison data from a controlgroup, it cannot be excluded that the treatment goals of theparticipants could not have been reached without SFBT. In addi-tion, the small number of participants limits generalization of thefindings. To what extent our findings will apply to other peoplewith MID is unknown. However, despite these limitations, thefact that several case studies showed positive treatment resultsdoes point to the potential of using SFBT for people with MID.Further research into the effects of SFBT that includes a controlgroup is needed to further assess the value of SFBT.

We conclude that SFBT provides an additional approach ofavailable therapeutic approaches for use with people with ID.There are several reasons why we make this statement.

First, SFBT focuses on skills rather than on deficits and rec-ognizes the expert status of people with MID. This is in line withthe present view of ID that focuses on empowerment. Second, weagree with Stoddart et al. (2001), who, in noting the strengths ofusing SFBT with people with ID, said “SFBT is a highly, struc-tured, active, and directive approach. It focuses on concrete andimmediate issues. The approach partializes problems by settinglimited and clearly defined goals, and it fosters an early and posi-tive relationship between clients and therapists” (p. 36). Third,SFBT encourages the involvement of carers in the therapeuticprocess. Because of their involvement in SFBT, professionalsmay develop more positive perspectives on the people with MIDand may become more aware of their resiliencies, resources andcompetencies, and in particular their abilities to come up with

solutions themselves (Lloyd & Dallos, 2006, 2008). Finally, there isevidence (MacDonald, 2007) that SFBT works equally well for allsocioeconomic groups. Although it was exploratory, this study’sfindings are important because most psychotherapy research andmany psychiatric studies show that outcomes are generally betterfor the higher socioeconomic groups. Yet, people with MID areoften economically disadvantaged and usually belong to lowersocioeconomic groups. The findings that they too can benefitfrom SFBT is encouraging. We therefore can conclude that SFBTcan be regarded as a valuable therapy, although we would alsopropose that further research in this area is needed.

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Solution-Focused Brief Therapy With People With Mild Intellectual Disabilities: A Case Series